10/11/2017

CMS Releases RAI Manual: What’s In It

The Centers for Medicare and Medicaid Services (CMS) released the updated RAI Manual on August 31, 2017 for use with Assessment Reference Dates (ARD) on or after October 1, 2017. There are two sections that are completely new, a new Activities of Daily Living (ADL) algorithm and some surprising coding instructions.  Many of the updates support CMS’s focus on person-centered care and better alignment between the Minimum Data Set (MDS), the Revised Requirements of Participation and Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” of the State Operations Manual.

Baseline Care Plan

As Phase 2 of the revised Requirements of Participation gets closer (effective November 28, 2017), it is not a surprise that the updated manual includes new language surrounding the Baseline Care Plan. Chapter 2 of the updated RAI manual, page 2-41, adds “Within 48 hours of admission to the facility, the facility must develop and implement a Baseline Care Plan for the resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of care (42 CFR §483.21(a)).”

Significant Change in Status

The word “major” has been added. (“A “significant change” is a major decline or improvement.”)  Three items have been added to list of declines:

• Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment;
• A new unstageable pressure ulcer/injury, a new deep tissue injury; or
• Emergence of a condition/disease in which a resident is judged to be unstable.

Examples in Section A, End of PPS Stay (A0310H) Corrected

Two examples in Chapter 3, on pages A-35 & A-36, have been corrected to reflect item A0310H = 1 and offers this rationale: Even though only an OBRA Discharge was required, when the Date of the End of the Medicare Stay is on the day of or one day before the Date of Discharge, MDS specifications require that A0310H be coded as 1.

In summary, A0310H = 1 every time a Medicare Part A stay ends, unless the stay has ended due to death.

The ADL coding rules have not changed, but the updated RAI manual offers clarification and a new ADL algorithm that makes coding Section G much easier.

CMS has also added four new bullet points to the Coding Tips and Special Populations section for G0110 (Activities of Daily Living (ADL) Assistance):

• Some residents are transferred between surfaces, including to and from the bed, chair, and wheelchair, by staff, using a full-body mechanical lift. Whether or not the resident holds onto a bar, strap, or other device during the full-body mechanical lift transfer is not part of the transfer activity and should not be considered as resident participation in a transfer.
• Transfers via lifts that require the resident to bear weight during the transfer, such as a stand-up lift, should be coded as Extensive Assistance, as the resident participated in the transfer and the lift provided weight-bearing support.
• How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting.
• When a resident is transferred into or out of bed or a chair for incontinence care or to use the bedpan or urinal, the transfer is coded in G0110B, Transfers. How the resident uses the bedpan or urinal is coded in G0110I, Toilet use. (page G-9 – G-10).

Additionally, this clarification was added to item G0600C, wheelchair (manual or electric): “Do not include geri-chairs, reclining chairs with wheels, positioning chairs, scooters, and other types of specialty chairs.” 

Section GG, Admission and Discharge Functional Performance 

Many clarifications were added to assist with coding this section, including the following: 

• Related to Admission functional assessment- “The assessment should occur, when possible, prior to the start of resident benefitting from therapeutic treatment interventions in order to determine the resident’s true admission baseline status. Even if treatment started on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment.”
• tThe Discharge functional assessment … “must be completed within the last three calendar days of the resident’s Medicare Part A stay, which includes the day of discharge from Medicare Part A and the two days prior to the day of discharge from Medicare Part A.”
• When coding the resident’s usual performance, “effort” refers to the type and amount of assistance the helper provides in order for the activity to be completed. The 6-point rating scale definitions include the following types of assistance: setup/cleanup, touching assistance, verbal cueing, and lifting assistance.
• Clinicians may code the eating item using the appropriate response codes if the resident eats using his/her hands rather than using utensils (e.g., can feed himself/herself using finger foods). If the resident eats finger foods with his/her hands independently, for example, the resident would be coded as 06, Independent.

These Coding Tips were added to clarify coding Wheelchair items GG0170R & GG0170S: 

• The intention of the wheelchair items is to assess the resident’s use of a wheelchair for self-mobilization at admission and discharge when appropriate. The clinician uses clinical judgment to determine if the resident’s use of a wheelchair is appropriate for self-mobilization due to the resident’s medical condition or safety.
• Do not code wheelchair mobility if the resident only uses a wheelchair when transported between locations within the facility. Only code wheelchair mobility based on an assessment of the resident’s ability to mobilize in the wheelchair.
• If the resident walks and is not learning how to mobilize in a wheelchair, and only uses a wheelchair for transport between locations within the facility, code the wheelchair gateway items at admission and/or discharge items—GG0170Q1 and/or GG0170Q3, Does the resident use a wheelchair/scooter—as 0, No. Answering the question in this way invokes a skip pattern which will skip all remaining wheelchair questions.
• Admission assessment for wheelchair items should be coded for residents who used a wheelchair prior to admission or are anticipated to use a wheelchair during the stay, even if the resident is anticipated to ambulate during the stay or by discharge.

Section H, Intermittent Catheterization 

CMS removed the word “sterile” from the definition of intermittent catheterization. This item (H0100D) will now be checked for residents who perform self-catheterizations in the facility using clean technique. 

Urinary Tract Infection (UTI) - Criteria Changed 

Code only if both of the following are met in the last 30 days:

1. It was determined that the resident had a UTI using evidence-based criteria such as McGeer, NHSN, or Loeb in the last 30 days, AND
2. A physician documented UTI diagnosis, (or by nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) diagnosis of a UTI in the last 30 days,

In accordance with requirements at §483.80(a) Infection Prevention and Control Program, the facility must establish routine, ongoing and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections. The facility’s surveillance system must include a data collection tool and the use of nationally recognized surveillance criteria. Facilities are expected to use the same nationally recognized criteria chosen for use in their Infection Prevention and Control Program to determine the presence of a UTI in a resident. 

Example: if a facility chooses to use the Surveillance Definitions of Infections (updated McGeer criteria) as part of the facility’s Infection Prevention and Control Program, then the facility should also use the same criteria to determine whether or not a resident has a UTI.  

Resources (links) were added to the RAI manual, (page I-9) to access Loeb, McGeer, and NHSN criteria. 

Section J - Intercepted Fall Clarified 

CMS understands that challenging a resident’s balance and training him/her to recover from a loss of balance is an intentional therapeutic intervention and does not consider anticipated losses of balance that occur during supervised therapeutic interventions as intercepted falls. 

Section L – Edentulous and Having Some Natural Teeth Clarified 

Edentulous is having no natural permanent teeth in the mouth. Complete tooth loss. 

The dental status for a resident who has some, but not all, of his/her natural teeth that do not appear damaged (e.g., are not broken, loose, with obvious or likely cavity) and who does not have any other conditions in L0200A–G, should be coded in L0200Z, none of the above. 

Section M – Several Clarifications 

Mucosal Pressure Ulcers, are not staged and therefore should not be considered when coding item M0210 “Does the resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher?”. Examples of mucosal ulcers include those related NG tubes, nasal oxygen tubes, endotracheal tubes, urinary catheters-if present these would not be coded in item M0210. 

Additional clarifications and examples have been added related to determining if a pressure ulcer was “Present on Admission” and/or if “New or Worsening” should be coded in item M0800. 

Section N – Opioid & Gradual Dose Reduction of Antipsychotics  

Clarifications include: 

• Medications that have more than one therapeutic category and/or pharmacological classification should be coded in all categories/classifications assigned to the medication, regardless of how it is being used. For example, prochlorperazine is dually classified as an antipsychotic and an antiemetic. Therefore, in this section, it would be coded as an antipsychotic, regardless of how it is used.
• Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs), which may or may not require laboratory monitoring, should be coded in N0410E, Anticoagulant.
• Melatonin has been added to the examples of herbal and alternative medicine products NOT counted as medications in section N. Do not code Melatonin as hypnotic.

NEW ITEM - N0410H, Opioid: Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 

NEW ITEM - N0450, Antipsychotic Medication Review
**Note- the look back period is since admission/entry, reentry, or prior OBRA assessment. (Does not include prior PPS assessment). This item will not be included on PPS assessments.

 

 

 

 

 

 

 

 

 

 

 

Several Coding Tips were added for these items, and include: 

• Do not include gradual dose reduction (GDR) that occurred prior to admission to the facility
• Physician documentation indicating dose reduction attempts are clinically contraindicated must include the clinical rational of why dose reduction in inadvisable
• Within the first year in which a resident is admitted on an antipsychotic medication or after the facility has initiated an antipsychotic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless physician documentation is present in the medical record indicating a GDR is clinically contraindicated. After the first year, a GDR must be attempted at least annually, unless clinically contraindicated.
• Do not count an antipsychotic medication taper performed for the purpose of switching the resident from one antipsychotic medication to another as a GDR in this section.
• In cases where a resident is or was receiving multiple antipsychotic medications on a routine basis, and one medication was reduced or discontinued, record the date of the reduction attempt or discontinuation in N0450C, Date of last attempted GDR.
• If multiple dose reductions have been attempted since admission/entry or reentry or the prior OBRA assessment, record the date of the most recent reduction attempt in N0450C, Date of last attempted GDR.
• Federal requirements regarding GDRs are found at 42 CFR §483.45(d) Unnecessary drugs and 483.45(e) Psychotropic drugs.

Update on Pneumococcal Vaccine – Item O0300A
“Up to date” in item O0300A means in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations.

• If a resident has received one pneumococcal vaccination and it has been less than one year since the resident received the vaccination, he/she is not yet eligible for the second pneumococcal vaccination; therefore, O0300A is coded 1, yes, indicating the resident’s pneumococcal vaccination is up to date.
  

Respiratory Therapy Clarification 

Respiratory therapy—only minutes that the respiratory therapist or respiratory nurse spends with the resident shall be recorded on the MDS. This time includes resident evaluation/assessment, treatment administration and monitoring, and setup and removal of treatment equipment. Time that a resident self-administers a nebulizer treatment without supervision of the respiratory therapist or respiratory nurse is not included in the minutes recorded on the MDS. Do not include administration of metered-dose and/or dry powder inhalers in respiratory minutes. 

Physician Examinations and Orders NO LONGER Required                   

CMS does not require completion of these items; however, some States continue to require its completion. It is important to know your State’s requirements for completing this item.  If the State does not require the completion of this item, use the standard “no information” code (a dash, “-”). 

Section P is now Restraints AND Alarms
NEW ITEM- P0200, Alarms
An alarm is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected, and may include bed, chair and floor sensor pads, cords that clip to the resident’s clothing, motion sensors, door alarms, or elopement/wandering devices.

  

• While often used as an intervention in a resident’s fall prevention strategy, the efficacy of alarms to prevent falls has not been proven; therefore, alarm use must not be the primary or sole intervention in the plan.
• Adverse consequences of alarm use include, but are not limited to, fear, anxiety, or agitation related to the alarm sound; decreased mobility; sleep disturbances; and infringement on freedom of movement, dignity, and privacy.
• P0200 will only be included on OBRA comprehensive and quarterly item sets.
• If an alarm meets the criteria as a restraint, code the alarm use in both P0100, Physical Restraints, and P0200, Alarms.
  • This item has raised a lot of concern. For a more comprehensive review of when alarms may also be restraints, see P0200: Alarms – Deeper Dive into Coding and Survey Implications.